Join Patient Reference Group

Shenley Green Surgery is in the process of establishing a Patient
Reference Group (PRG) to gain the views of our registered patients and ensure they are involved in decisions about the range and quality of the services
provided by our practice.

If you are interested in becoming a PRG member, please submit your details using the form below. Providing this information will help us to
ensure that the PRG is as representative as possible of our practice population as a whole. The information you supply will be used lawfully,
in accordance with the General Data Protection Regulation (GDPR).

1 Your Details

Your name

Date of BirthPlease provide in the format dd/mm/yyyy

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

E-mail Address

Postcode

Gender

Which of the following ethnic backgrounds do you most closely identify with?

How would you describe how often you come to the practice?

Click here if you would like to receive an e-mail confirming the form has been received by Shenley Green Surgery.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toShenley Green Surgery
•
22 Shenley Green Lane, Selly Oak, Birmingham, B29 4HH.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.